Stuart Robinson began working at North Tees and Hartlepool NHS Foundation Trust in a temporary role after university, but has since made the move into a career within clinical coding.
We sat down with Stuart to discuss just what a clinical coder does and what his role involves:
What is a clinical coder?
At its most simplistic, we record information about every patient that visits the hospital, investigating all aspects of their journey with us from start to finish.
Effectively, we are the end users of clinical information – which can include clinical notes, scans, and pathology or endoscopy results – everything that has happened during a patient’s time with us.
We translate that patient’s journey or ‘episode’ into a set of codes. So everything that could go wrong in the human body, every disease or treatment, has a code (as classified by the World Health Organisation).
What led you to a career in clinical coding?
I’ve been working within the trust in some capacity since 2008. I had gotten a temporary job as a filing clerk after university, figuring I would work in that role until I had worked out my next move.
I had been trying different roles on for size, and had decided that I wanted to take on a new challenge – I’d discovered I was quite detail orientated, but wanted something that would offer something new outside of the jobs I’d done in the past.
So it was during my time working as an admin in physiotherapy (and through my clinician wife) that I discovered I felt quite at home with medical terminology. Then I was alerted to a vacancy within the clinical coding team.
It took two attempts, but eventually in March 2015, I was successful and found myself taking on a new and challenging role as a clinical coder.
What might a typical day look like?
As you might imagine, a lot of the work involves looking through the patients’ active clinical notes, discharge summaries, ICE, PACS record systems – anything that gives us a full overview of what the patient has been through.
We start trying to translate this into code using our knowledge and our books. Generally, we can work through the notes without issue, but we may need to consult with nurses, doctors and clinicians to ensure we have correctly interpreted clinical notes.
The number of patient notes we get through will ultimately depend on the complexity of the episode of care, so there can be a fair bit of detective work when you have a more complex case to work through. We will then sometimes go into a clinical area to work with the clinicians to improve processes and to troubleshoot.
We might also have some internal auditing that day, so a sample will be pulled and those auditing will have to go through things with a fine-tooth comb to assess how well things have been coded.
How does your role improve the patient journey?
We are definitely a cog in a larger machine, but the coding of a patient’s episode of care means we are generating a tariff that ensures a NHS trust gets paid (and monies can be reinvested into our services). It also means other teams can then track raw statistics/data to help people to see health trends by regions or by country. From this data, more can then be done to focus on improving treatments for our patients.
What can you tell us about qualifications and job development?
I will say that to be a good clinical coder – having a keen mind and being very detail orientated is important. And it certainly doesn’t harm to have a base understanding of anatomy, biology and physiology.
If you come in at entry level as a trainee, you will do a foundation course, which takes around two months to complete. During this course you will learn the fundamental standards and rules of coding. I loved this introduction, as it’s your gateway into clinical coding and was such an eye opener.
You will then have a year or two of learning the ropes and generally building up your skills and knowledge before you are expected to work towards getting your accredited clinical coder (ACC) qualification.
For me, the qualification took around six months of study on an evening, culminating in a coding exam (just what it sounds like) and a theory exam which includes questions on anatomy and physiology.
You may be asked later if you want to specialise in a certain area – I’ve chosen to specialise in orthopaedic medicine – so I’ll code more notes for that area. It just means I can become really proficient at understanding the medical terminology and codes for that area, so I can be a subject matter expert.
What are your favourite aspects of the job?
The learning is a big part of it – I was drawn in by coding and being able to learn a new skill and to challenge myself. There can be a bit of detective work and problem solving with coding at times, so being able to draw out that detail and to check you are correctly interpreting the notes is very satisfying.
But I also quite like to meet people, and although office based I do get to go out onto wards, meet teams and to work collaboratively to improve processes. It’s nice to be able to put faces to the names you may have been speaking to for weeks over email!